Provider Demographics
NPI:1790747350
Name:BRECKENRIDGE, ROBERT JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:BRECKENRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:401 E OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5800
Mailing Address - Country:US
Mailing Address - Phone:580-233-4300
Mailing Address - Fax:580-350-6401
Practice Address - Street 1:401 E OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5800
Practice Address - Country:US
Practice Address - Phone:580-233-4300
Practice Address - Fax:580-350-6401
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1794171100000X, 204C00000X, 207RE0101X, 207RI0001X, 2081N0008X, 2081P2900X, 207R00000X
OK37D2190466207RI0001X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171100000XOther Service ProvidersAcupuncturist
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110230825OtherRR MEDICARE
OK100257360DMedicaid
OK37D2190466OtherCLIA
OK100257360DMedicaid